Provider Demographics
NPI:1497794838
Name:MALLYA, RACHEL JACOB (DMD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:JACOB
Last Name:MALLYA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2302
Mailing Address - Country:US
Mailing Address - Phone:610-352-7766
Mailing Address - Fax:
Practice Address - Street 1:27 GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2302
Practice Address - Country:US
Practice Address - Phone:610-352-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026140-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist